NCLEX review psych

The nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which issue?

The parameters of the relationship

A nurse is preparing a hospitalized client for discharge. In evaluating the coping strategies learned during hospitalization, the nurse would recognize which statement by the client as an indication that further teaching is needed?

"I know that I won't become depressed again."

A long-term care resident with a history of paranoid schizophrenia refuses to eat & tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

A nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering 2 people. The client says, "I don't know what I did wrong. His Dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall 'to see if it landed on its feet' & stole money from me & denied it, his sister 'covered' for him." The nurse plans to make which therapeutic response to the client?1. "It seems as if you or your daughter feel regret."

"It seems as if you or your daughter feel regret"

A client is admitted to the in-patient unit & is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant & anxious. The client's mother begins to cry & states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together & discuss any concerns you may have?"

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, & I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse should be therapeutic?

"It's okay to grieve & be angry with your daughter & anyone else for a time."

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which therapeutic response to the client?

"Tell me about your difficulty sleeping"

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?

"The leader of this self-help group is the nurse or psychiatrist."

A client who is experiencing suicidal thoughts states to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" The appropriate initial nursing response is:

"What do you mean by that?"

A 2-year-old child is a suspected victim of child abuse. The nurse is e parent, would indicate a characteristic associated with child abuse?

"When I tell my child to do something once, I don't expect to have to tell them again."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking about hurting yourself?"

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of anorexia nervosa & associated disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.

- "I'm going to do whatever it takes to get better." - "I'll go & participate as much as I can in the group discussions."

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

- "My husband always brings me flowers & apologizes after he hits me." - "My boyfriend yells & accuses me of having an affair if I am late after work." - "I have bruises all over my body. I am frequently clumsy & fall a lot."

The LPN is assisting the RN in admitting a client with an exacerbation of schizophrenia & knows that which s/s displayed by the client are considered positive symptoms? Select all that apply.

- Hallucinations - Delusions - Neologisms

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate & who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

- Incoordination - Mental confusion - Muscle hyperirritability

Which are appropriate interventions for caring for the client in alcohol withdrawal? Select all that apply.

- Monitor VS - Provide a safe environment - Provide reality orientation as appropriate - Address hallucinations therapeutically

A client has just been admitted to the mental health unit with a diagnosis of OCD. The nurse observes the client for compulsive behavior that denotes repetition in which?

Actions

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer & asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which of the following community groups?

Al-Anon

A client is scheduled to have electroconvulsive therapy (ECT). The nurse tells the client that:

Amnesia of events occurring near the period of the therapy is common.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and do which?

Assign a staff member to the client who will remain with him or her at all times

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for this phase?

Assist in making appropriate referrals

The nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. Which finding requires the nurse's immediate intervention?

Client's inadequate attention to ADLs & poor nutritional intake

Which data indicates to the nurse that a client may be experiencing ineffective coping following the loss of her spouse?

Constantly neglects personal grooming

The nurse enters a client's room, & the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder & that the admission was a voluntary admission. The nurse reports the findings to the RN & expects that the RN will take which action?

Contact the HCP

An assembly-line manager in a local auto parts factory was told that he would be laid off if his line didn't meet the hourly quota. He promptly went to his workers & threatened to fire anyone who was found taking even 1 min extra on their break. This is an example of:

Displacement

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose?

Disulfiram (Antabuse)

The nurse is preparing a care plan for the client with OCD. The nurse should focus on which as the primary means to accomplish work with this client?

Goals & objectives

Punishment & abandonment were how people treated the mentally ill in the Dark Ages. These practices continued until the 17th & 18th centuries. Dr. Philippe Pinel of France advocated which practice of care that's still used today?

Humane care with record keeping of behaviors

Assessment of an older adult patient will be enhanced if the nurse:

Identifies & accommodates physical needs 1st

A nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which of the following s/s associated with opioid withdrawal?

Increased pulse & BP, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, & mydriasis

The nurse is preparing to admit a client diagnosed with OCD to the mental health unit. The nurse should observe this client for which behavioral characteristic(s)?

Inflexible & rigid

The nurse is caring for a client who was recently admitted for anorexia nervosa. Upon entering the client's room, the nurse finds the client in the middle of a series of sets of rapid sit-ups. Which action should the nurse take?

Interrupt the client & take her for a walk

The nurse who is credited for being the 1st psychiatric nurse in the U.S. is:

Linda Richards

A client tells a nurse that he is feeling out of control. The nurse observes that the client is pacing back & forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room & talk about their feelings

An intoxicated pt is brought to the ER by local police. The pt is told that the HCP will be in to see the opt in about 30min. The pt becomes very loud & offensive & wants to be seen by the HCP immediately. The nurse assisting to care for the pt would plan for which appropriate nursing intervention?

Offer to take the pt to an exam room until they can be treated

A nurse is assigned to care for a pt who's experiencing disturbed thought processes. The nurse is told that the pt believes that the food is being poisoned. Which communication tech does the nurse plan to use to encourage the pt to eat?

Open-ended questions & silence

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Opened ended questions & silence

The nurse observes that a client is psychotic, pacing, & agitated & is making aggressive gestures. The client's speech pattern is rapid, & the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

Provide safety for the client & other clients on the unit

A teenager wrecks the family care by rear-ending a truck turning left. The teen says. "It wasn't my fault. I came over the rise & that truck was just sitting there. It was his fault for turning left." What defense mechanism is the teen using to deal with his situation?

Rationalization

A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. The priority nursing intervention is to:1. Remain with the client at all times

Remain with the client at all times

A client comes to the ER following an assault & is extremely agitated, trembling, & hyperventilating. Which initial nursing action is appropriate?

Remain with the client until the anxiety decreases

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

A woman comes into the emergency room following an assault. Her symptoms include hyperventilation, pacing, rapid speech, & headache. The nurse correctly determines that the client is experiencing which level of anxiety?

Severe

The nurse is instructing a wife to give insulin injections to her husband. The wife is unable to sit still, frequently asks to repeat parts of the instruction for understanding, & sighs often with rapid respirations. What degree of anxiety is the wife experiencing?

Severe

A nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse would expect to note which behavior in the client?

Slowed walking & talking

A crisis occurs when a person:

Suffers a stressor & responds with ineffective coping efforts

An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which of the following would be least effective in preparing the client to return to a safe, effective care environment?

Suggest that the mother's boyfriend move out of the home

A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is most likely to react to a disagreement with this fellow employee by:

Telling a friend that this employee hates her or him Rationale: The defense mechanism of projection is an unconscious process that projects emotionally unacceptable feelings to other people, objects, or situations & casts the blame onto another.

A nurse is collecting data from a client in crisis & is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide?

The client has an immediate plan for a suicide attempt

The nurse is reviewing the record of a client admitted to the mental health unit & notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand & obtain release from the hospital

Personality refers to:

The relatively consistent set of attitudes & behaviors particular to an individual

A 52 yo suffered cardiac arrest from a MI. During his acute care stay in the hospital, the patient flirts with all his female nurses. When he's asked to stop, he withdraws & later complains of chest heaviness. What's a possible explanation of the patients behavior?

Threatened self-concept

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, the nurse understands that it is important that:

Until the client's thinking is cleared, the nurse may need to assist the client with grooming & nutrition.

A client with delirium becomes agitated & confused at night. The best initial intervention by the nurse is which

Use a nightlight & turn off the tv

A nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions r/t safety for the clients will be provided at which of the following times?

Weekends

In the 18th century, the English Quaker who advocated human care & built an asylum to reflect a household was:

William Tukes

The nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within which time after cessation or reduction of alcohol intake?

Within a few hours

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room & notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client & offer to take her for a walk

The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?

Sibling stating, "I don't feel safe around my brother."

A nursing assistant is assigned to work with a nurse to care for a client who was at risk for suicide. Which of these statements made by the nursing assistant indicates to the nurse that the nursing assistant understands suicide?

"Discussing suicide with a client is not harmful."

The best rationale for using group therapy as an accepted way of treatment of clients in the milieu is because:

Group therapy provides a social mechanism in which a client can relate to peers & validate thoughts & feelings in a realistic environment

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations & anxiety & determines that the client understands the interventions when the client states which?

"I can call my therapist when I'm hallucinating so I can talk about my feelings & plans & not hurt anyone."

During a group meeting, a client diagnosed with PTSD verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic

"I can see that you are upset about this. Let's talk about this some more."

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night & states, "My roommate will steal me blind." Which is an appropriate response by the nurse?

"I hear what you are saying, but I don't share your belief."

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends & I went out for lunch today."

After a few days of hospitalization, a patient is participating in plans to be transferred to a rehab facility to continue therapies to enhance his ADLs. Which statement indicates the patient is beginning to adjust to this new situation & future?

"My late wife wouldn't want me to be by myself if I can't take care of myself"

A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which of the following would be the therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which?

"What do you find difficult about this situation?"

A nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which of the following nursing responses would be therapeutic?

"Your HCP wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?"

A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the following clients assigned to the nurse is at the highest risk for committing suicide?

A 75-year-old male with severe depression & cancer

Anxiety is possible to define as:

A vague feeling of apprehension

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior & is at r/f potential harm to others. The nurse should avoid which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

A nurse is assisting in a group therapy session. During this session, the members are identifying tasks & boundaries. The nurse understands that these activities are characteristic of which stage of group development?

Beginning phase

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses & begins to walk out of the hospital room. The appropriate nursing action is to:

Call the nursing supervisor

A client was admitted to a medical unit with acute blindness. Many tests are performed & there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-&-run car crash, in which a family of 3 was killed. The nurse suspects that the client may be experiencing a:

Conversion disorder

In the 20th century, changes in the delivery of mental health care resulting from the development of electroconvulsive therapy & psychotherapeutic drugs brought about the phenomenon of:

Deinstitutionalization

Martha Mitchell, RN, worked with President Carter to develop the Mental Health Care Systems Act, which the U.S. Congress passed in 1980. This act established block grants for mental health care. What occurred as a result of this act?

Deinstitutionalization

A college student is brought to the ER by her roommate. The roommate states that when the patient returned from her date she was crying & said she was raped. The patient recounts the evening's events, cracking jokes about her dates trouble keeping an erection & asking if the nurse knows where she can get a replacement for her favorite outfit, which has been torn. This defense mechanism is:

Dissociation

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

A nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the ER; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A nurse is assigned to care for a pt admitted to the hospital after sustaining an injury from a house fire. The pt attempted to save a neighbor involved in the fire but, in spite if the pt's efforts, the neighbor died. Which action would the nurse take to enable the pt to work through the meaning of the crisis?

Inquiring about the pt's feelings that may affect coping

Defense mechanisms are:

Means of managing conflict

A nurse in the ER is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, & physical evidence has been collected. The nurse notes that the client is withdrawn, confused, & at times physically immobile. These behaviors are interpreted by the nurse as:

Normal reactions to a devastating event

The highest priority in crisis intervention is:

Patient safety

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 & began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which?

Protection from the risk of intimacy

The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?

Reported hopelessness

A key tool the nurse uses when establishing a relationship with a patient with a psychiatric d/o is:

Self-reflection

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy workup. In planning care for this client, it is important that the nurse understand that the client is suffering from which condition?

Somatization disorder

A suicidal client is admitted to the hospital. The nurse reviews the nursing care plan & notes documentation of a nursing diagnosis of dysfunctional grieving r/t the loss of a spouse. The client progresses well & is approaching discharge. Which of the following is an appropriate outcome for this client?

The client verbalizes stages of grief & plans to attend a community grief group

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say which?

"I no longer feel that I deserve the beatings my husband inflicts on me."

A nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week & this is my day of rest. I'll get up at 11:30." The nurse's best response should be:

"Let me know if you change your mind & I'll get you something to eat."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday" even though it has been a few months since the incident. The appropriate nursing response is which of the following?

"Tell me more about the incidence that causes you to feel like the rape just occurred."

A pt says to the nurse "I'm going to die, & I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying" The therapeutic response by the nurse is:

"You're feeling angry that your family continues to hope to be 'cured'?"

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse makes which therapeutic response to the client

"You've been feeling like a failure for a while?"

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

- Communicate expected behaviors to the client - Assist the client in developing means of setting limits on personal behavior - Follow through about the consequences of behavior in a non-punitive manner - Be clear with the client regarding the consequences of exceeding limits set regarding behavior

A 24 yo is recovering from pelvic & leg fracture suffered in an auto accident. He has to be immobilized for 2 wks & yells at the nurse. "Why does it have to take so long to heal?" What's the best approach in regard to managing stress to benefit the immune system to heal?

Confide in friends & family about frustrations

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder & mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?

Constant physical activity & poor oral intake

A nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which of the following?

Contracts & immediately available crisis resources

Lab work is prescribed for a pt who has been experiencing delusions. When the lab tech approaches the pt to obtain a specimen of the pt's blood, the pt begins to shout "You're all vampires. Let me out of here!" The nurse who is present at the time should respond by stating which of the following?

"Are you fearful & think that others may want to hurt you?"

The nurse is admitting a client who has a history of bipolar disorder to the hospital, & the HCP has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply.

- Sets limits on behavior - Provide high caloric nutritional intake - Distract or redirect the client. - Decrease environmental stimulation

The police arrive at the ER with a client who has seriously lacerated both wrists. The initial nursing action is which?

Examine & treat the wound sites

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time?

Initiate confinement measures

The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening & shouting at everyone, & is refusing to participate in therapy. The nurse takes which initial action?

Provide for safety by recognizing the level of client anxiety and setting limits.

The nurse reviews the activity schedule for the day & determines that the best supervised activity that the manic client could participate in is which?

Ping Pong

A nurse working in the long-term care facility understands which of the following concepts r/t depression in the older client?

Depression in the older client is often undertreated.

When caring for a client who has been raped, which intervention would the nurse implement during the examination?

Explaining procedures to be completed & why the procedures are necessary

A client experiencing a severe major depressive episode is unable to address ADLs. The appropriate nursing intervention is which?

Feed, bathe, & dress the client as needed until the client can perform these activities independently

A client who is diagnosed with pedophilia & recently has been paroled as a sex offender says, "I'm in treatment & I have served my time. Now this group has posters all over the neighborhood with my photograph & details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which?

Evidence of the client's altered & distorted body image

The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client & understands that the client with anorexia nervosa manages anxiety by which action?

Observe rigid rules & regulations

A client has reported that crying spells have been a major problem over the past several weeks & that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, & the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?

Weight loss

Lab work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond by stating which?

"Are you fearful & think that others may want to hurt you?"

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use & what effect does it have on you?"

An older client is a victim of elder abuse, & the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates the client has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance"

The nurse is reviewing the discharge plan with a female teenager with anorexia nervosa & reinforces the importance that the teenager attends a meeting of the local chapter of Anorexia Nervosa & Associated Disorders. Which response by the teenager indicates that she will likely be compliant with this plan?

"I'm going to do whatever it takes to get better."

A mental health nurse on the eve shift is receiving report about a client who was admitted to the nursing unit. The nurse is told that the client was admitted by involuntary status. Based on this type of admission, the nurse would expect which statement is an aspect of the client's care?

The client is in need of psychiatric treatment

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

A client who has been drinking alcohol on a regular basis admits to having "a problem" & is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

AA

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has which?

Agoraphobia

A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder?

Altered thought process

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which?

Sit beside the client in silence & verbalize occasional open-ended questions.

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which?

Client involvement in goal setting

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the HCP

A client was admitted to a medical unit with acute blindness. Many tests are performed, & there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-&-run car crash in which a family of 3 was killed. The nurse suspects that the client may be experiencing which?

Conversion disorder

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

DUI conviction resulted in a 1-year suspended license

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door & is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which?

Denial

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive & threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which?

Escort the manic client to his/her room

The nurse is assigned to assist in the care of a client with OCD. The nurse should place 1st priority on which action when planning care for this client?

Establish a trusting nurse-client relationship

A client has been brought to the ER after attempting to commit suicide by hanging. The nurse should take which nursing action first?

Examine the neck area & assess the airway

Following a group therapy session, a client approaches the nurse & verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the RN & expects that the RN will take which action?

Get a written prescription from the HCP & obtain an informed consent

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which?

HTN, disorientation, hallucinations

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room & takes which action?

Have the client open the gift with the nurse present

The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem?

Maintain a well groomed appearance

The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?

The false belief that one is being singled out for harm by others

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse should make which appropriate response?

"It sounds as though you are feeling all alone right now."

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back & forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room & talk about his feelings

The nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of which condition?

PTSD

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation & urinary retention, knowing that these problems are likely caused by which?

Psychomotor retardation & side effects of medication

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse expects which?

The client presents a harm to self

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?

The client will participate in the treatment plan

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client?

"You've been feeling like a failure for a while"

Which client is most likely at risk to become a victim of elder abuse?

A 90 yo woman with Parkinson's disease

On data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe?

A fear of leaving the house

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image; the client reports an extreme fear of public speaking. The nurse analyzes this information & determines that the client's fear would be considered which diagnosis?

A social phobia

Stress is:

A response to any demand made upon the individual

A nurse is monitoring a client that is in seclusion. The nurse determines that the client is safe to come out of seclusion when the client states:

"I am no longer a threat to myself or others"

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, & using aggressive gestures & rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client & other clients on the unit.

A client has been hospitalized & has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics & coping response styles & has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy & I'm sad, I'm excited & I'm scared. I know that I have to work hard to be strong & that everyone isn't going to be as helpful as you people."

A nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which of the following?

"Our relationship is a therapeutic and helping one."

The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?

"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

"Tell me more about what causes you to feel like the rape just occurred."

A client says to the nurse, "I'm going to die, & I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

"You're feeling angry that your family continues to hope for you to be 'cured'?"

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply

- Communicate expected behaviors to the client - Assist the client in developing means of setting limits on personal behavior. - Follow through about the consequences of behavior in a nonpunitive manner. - Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is accurate regarding depression & the older client? Select all that apply.

- Depression in an older person is likely to have physical manifestations. - Some indications of dementia may actually originate as depression. - Suicide is a frequent cause of death among the older population.

The nurse in the mental health unit reviews the therapeutic & nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

- Restating - Listening - Maintaining neutral response - Providing acknowledgment & feedback

The RN has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the LPN use to assist this client in meeting this goal? Select all that apply.

- Stay with the client - Administer anxiolytics medications if prescribed. - Ensure the client is in an environment with little stimuli.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2 bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?

A client's response to a crisis is individualized, & what constitutes a crisis for 1 person may not constitute a crisis for another person.

A nursing student is asked to identify the characteristics of bulimia nervosa. The nursing instructor intervenes if the student identifies which incorrect characteristic of this disorder?

Body weight well below ideal range Rationale: Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, the client demonstrates enlargement of the parotid glands with dental erosion & caries if the client has been inducing vomiting. Electrolyte imbalances are present.

A pt is admitted to a psych unit for treatment of psychotic behavior. The pt is at the locked exit door & is shouting "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as:

Denial

A nurse is caring for a client who has a history of opioid abuse & is monitoring the client for signs of withdrawal. Which of the following observations, if made by the nurse, are indicative of the clinical manifestations associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, & diarrhea

A 14 yo is having a difficult adolescence. Over the summer, she grew 3 in & developed large breasts. 1 day, after boys teased her & imitated her figure, she went to the school nurse crying. What's the 1sst step for the nurse to take?

Have her tell in detail what happened

A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling & reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by:

Increasing the level of suicide precautions

A client with Alzheimer's disease became very agitated when a group of children came to sing & dance at a long-term care facility. The nurse should use which piece of information when approaching the client about this behavior

Individuals with Alzheimer's disease have difficulty tolerating excess stimulation & changes in routine.

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, the nurse should:

Inform the client that she is being secluded to help regain control of self

A nurse has been closely observing a client that has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which of the following nursing interventions is least helpful for this client at this time?

Initiate confinement measures

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Look for organic causes of the paralysis.

A nurse is employed at a drug abusers' residential treatment center. The nurse is preparing for the arrival of a new client & prepares to explain to the client that the emphasis of the center is on group & social interaction, & that rules & expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is which of the following?

Milieu therapy

A nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's BP is elevated at 160/100 mm Hg. Based on this finding, the appropriate nursing action would be to:

Notify the RN

An intoxicated client is brought to the ER by local police. The client is told that the HCP will be in to see the client in about 30 minutes. The client becomes very loud & offensive & wants to be seen by the HCP immediately. The nurse assisting to care for the client should plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves:

Re-experiencing recollections of the trauma

A CEO was admitted to the orthopedic ward with pelvic fracture, wrist fracture, & multiple contusions & abrasions from an auto accident. She yells for the nurse every 5 min, refuses to use her call light, & breaks out in tears when she doesn't get her way. This coping behavior is termed:

Regression

A nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings r/t loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior?

The client is displaying typical behaviors that can occur during termination

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," & "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse should suggest which?

The mother should restrict the amount of chocolate & caffeine products in the home

A nurse in a psych unit is assigned to care for a pt admitted to the unit 2 days ago. On review of the pt's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse would expect which of the following?

The pt will participate in t he treatment plan

A nurse is assisting with the data collection on a pt admitted to the psychiatric unit. The nurse reviews the data obtained & identifies which of the following as a priority concern?

The pt's report as a priority of suicidal thoughts

A male phobic client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend & states that he "cannot sing." Which of the following responses by the nurse would be therapeutic?

"Perhaps you could just enjoy the music without singing."

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement should be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

The nurse notes that a client with AIDS appears anxious & is reluctant to ask questions. Which action should the nurse take to best address these observations?

Discuss common fears & questions expressed by other clients with the same diagnosis